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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> �-) 1� 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> U( P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Heal/►th Services. ,> <br /> Job Address • 1 Ari O /V City��GK�1r Lot Size/Acreage 3 �< q <br /> Owner's Name A CA Address 5 K YAE Phone � 1 ` S 5 <br /> Contractor e�J:Lg Gro SS Address too Illyt i 1 a Lice+ Q721 t Phone —&O <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT O DESTRUCTION Out of Service Well O <br /> PUMP INSTALLATION SYSTEM REPAIR O OTHER O Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK 100 SEWER LINES DISPOSAL FLD1 0 PROP. LINE "6'0 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> CI Industrial O Open Bottom O Manteca Dia. of Well Excavation I1 Dia. of Well Casing 6 <br /> ;4,oUomestic/Private !Gravel Pack O Tracy Type of Casing JoVC Specifications r--w <br /> I"1 Public Ll Other n Delta Depth of Grout Seal [da Type of GroutCe-At 0 n <br /> I I Irrigation IL%J 0--.Approx. Depth I I Eastern Surface Seal Installed by�','�t]fi'S ►S�� /\'J <br /> Repair Work Done 0 Type of Pump S'V19 H.P. /A: State Work Done Nrs <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE O No. & Length of lines, Total length/size <br /> FILTER BED O Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size _ Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all <br /> required inspections. Complete drawing on reverse side. <br /> Signed X `�C 6 .tom�✓4tTl.. Title: Pl 44-. Date: 6—17 <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by Date 1 _ Area <br /> Pit or Grout Inspection by 6 �� 7 Final Inspection by Date�� 7 <br /> Additional Comments: <br /> Applicant — Return ell copies to: Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> INFOAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY y DATE PERMITNO. � <br /> + EH 13.24 IREV.1 5) N� 1" QCS /t <br />